Download Radiology findings can help support your physician queries

Furthermore, you have to consider that the surgeon
did not take the patient to the operating room based on
the CDI specialist’s query about the patient’s renal status.
Additionally, the MCC that ultimately drove the reimbursement level was provided independently by the cardiology
consultant, with no prompting from the CDI staff.
Would it surprise the CDI director, then, to learn that
the true financial impact of the CDI specialist in this
instance was $0? The documentation of the chronic kidney
disease is, of course, important to the completeness and
accuracy of the record on this patient, and SOI or ROM
may be affected. But claiming any direct ­financial benefit
from the CDI specialist’s involvement with this patient’s
documentation is not warranted.
Baseline case-mix index
So, the baseline DRG is the DRG that would have been
coded and billed without the intervention of the CDI specialist. The average weights of the actual baseline DRGs can
be used to compute a case-mix index (CMI) in an analogous
fashion to using the average weights of the billed DRGs,
even though most hospitals don’t use this metric.
In the sample chart on p. 14, the baseline CMI is shown
with the red line, and the billed CMI, the one traditionally
­reported, is shown with the blue line. In the early stages of
this CDI program, the difference between the two values
appears to be due to the impact of the CDI staff, as one
might expect. But notice that the baseline CMI increases
over time—this implies that the physicians have learned
to document better. While the gap between the two lines
narrows over time, the benefits seen in the billed CMI continue to be positive. A rise in the baseline CMI reflects the
“training effect” of having a CDI program, which cannot be
discounted.
Conclusion
Selection of the baseline DRG should be done carefully, honestly, and precisely. Make sure that you have control
over the designation of the baseline DRG, or at least fully
understand how it was defined if you are using a software
program or consultant.
Doing so will help you ensure that your reports are
not artificially inflated by incorrect metrics or spreadsheet
calculations. Similarly, comparing the baseline CMI to the
billed CMI can provide valuable insights into potential
training effects on the physicians, and can help to identify
opportunities for further education.
If you don’t understand this component, you won’t have a
firm grasp of your program’s value at its most basic level.
Editor’s note: Elion is founder of ChartWise Medical Systems, Inc., in
Wakefield, RI. He has more than 40 years of experience in computing and
more than 25 years of experience in medical computing and information
standards. Contact him at [email protected].
Radiology findings can help support your physician queries
by Lynne Spryszak,
RN, CCDS, CPC-A
A patient’s medical record contains
a wealth of information about his or
her hospital encounter, including diagnoses, treatments, operative reports, and
ancillary notes. Unfortunately, much
of the detailed information found in a patient record is not
codeable—in other words, it is not information that may
be used for diagnosis code assignment. Coders may only use
­documentation contained in select portions of the record—
that which is provided by “hands-on” providers (i.e., those
providers legally accountable for establishing a diagnosis).
Radiology reports, such as CT and MRI scans, x-rays,
and ultrasounds, frequently contain detailed information that can lead to more specific code assignment. Coding
Clinic advice supports the use of radiology findings to
obtain additional information regarding the coding of the
specific site of fractures. See the following references for
more ­information: Coding Clinic, First Quarter 1999, p.
5 (fracture site specified in radiology report), and Coding
Clinic, Second Quarter 2002, p. 3 (ED coding using the
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October 2011
15
r­ adiological ­findings). Note, however, that this guidance does
not pertain to assigning diagnosis codes for conditions that the
treating provider does not specifically identify or document.
with a cerebral hemorrhage or stroke has cerebral edema or
compression of the brain, which is why it is appropriate to
report these conditions when present.
Clues in the documentation
Queries for secondary conditions
Specific information often found in CT or MRI scans
can assist with diagnoses of cerebral edema or compression
of the brain. These two diagnoses, when reported, add severity to a record because they are considered MCCs in the
MS-DRG system. They also represent increased ROM in
other classification systems. These two diagnoses frequently
trigger the following ­interventions:
»»Intracranial pressure (ICP) monitoring
»»Surgical intervention (e.g., evacuation of an intracranial
hemorrhage or insertion of a drainage device)
»»Insertion of a shunt and/or treatment with medications to
reduce intracerebral pressure
Review the Uniform Hospital Data Discharge Set guidelines for reporting secondary diagnoses before querying the
provider. For example, before submitting a query, determine
whether the condition is the subject of clinical evaluation,
diagnostic testing, therapeutic treatment, or increased nursing care, or whether it caused an increased length of stay
(LOS). If so, then it would be appropriate to query for the
potential secondary corresponding diagnosis.
When reviewing radiology reports, take the following
approach:
»»Look for terms such as “midline shift,” “compression of
the fourth ventricle,” or “space occupying lesion” (often
used to describe intracranial tumors).
»»Look for any surgical treatments provided, such as ICP,
decompressive craniectomy, lumbar puncture, or insertion
of a subdural evacuating port system drain (interventions
designed to reduce intracranial pressure). Physicians perform some interventions at the bedside and often do not
document them. These may beoverlooked if a thorough
review of the progress notes is not performed.
»»Review the medication record for administration of IV
steroids, IV mannitol or Osmitrol®, diuretics, or hypertonic saline designed to reduce edema. Patients with
complex brain injuries may be followed by a neurologist,
neurosurgeon, intensivist, or all three. Their documentation may include specific diagnoses, but coders should not
assume that if the condition is not listed in the physicians’
notes, it is insignificant.
»»Assess for additional resources such as surgical intervention or physical/occupational/speech therapy. Coders
should review these notes for evidence of neurologic deficits that provide additional support for reporting higheracuity diagnoses.
According to St. John Ambulance, brain (or cerebral)
compression:
…Occurs when there is a build-up of pressure on the brain.
This pressure may be due to one of several different causes, such as an
accumulation of blood within the skull or swelling of injured brain
tissues. Cerebral compression is usually caused by a head injury.
However, it can also be due to other causes, such as stroke, infection,
or a brain tumor. The condition may develop immediately after a
head injury, or it may appear a few hours or even days later. For this
reason, you should always try to find out whether the casualty has a
recent history of a head injury.
Compression of the brain and cerebral edema are both
serious conditions that can lead to herniation of the brain,
brain cell death, and long-term deficits. These conditions
often go undocumented because providers assume that a diagnosis of cerebral hemorrhage, brain tumor, or stroke includes
anything related to the focal diagnosis. Providers also assume
that because these conditions may be evident from findings
summarized in the CT and/or MRI scan, there is no need to
document these conditions in their own notes.
This is where a thorough review of radiology reports
provides the clinical information to support a provider
query for appropriate additional secondary diagnoses such
as ­cerebral compression or cerebral edema. Not every patient
Sample scenario illustrates query opportunity
Consider a patient who is on your census in the medical
ICU of a large tertiary center. The ­admitting or principal
diagnosis is “non-traumatic intracerebral ­hemorrhage.” The
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October 2011
© 2011 HCPro, Inc.
patient’s wife found him unresponsive on the living room
floor on April 6 and called 911. The patient has a history of
hypertension, and his wife states that the patient “always forgot to take his medications.” A CT scan and MRI confirm
an intracerebral hemorrhage with evidence of a midline shift.
Upon arrival to the emergency department (ED), the
Glasgow coma score total was 8 (eye 2, verbal 2, motor 4).
One day later, the score is 3 (eye 1, verbal 1, motor 1). The
patient requires emergency surgery for evacuation of the
intracerebral bleed.
When deciding to query for the additional diagnosis of
“compression of brain,” consider that the size of the skull is
finite—it cannot expand to allow the uninjured brain tissue
to “get out of the way” of the hemorrhage, which is increasingly taking up space. As the hemorrhage progresses, brain
tissue is compressed against the rigid skull because it has
nowhere else to go.
Documentation of “midline shift” indicates the brain
tissue is shifting across the hemispheric midline. Not every
patient with a subarachnoid hemorrhage needs surgical intervention. Physicians may monitor and treat small hemorrhages only with medication, so a diagnosis is needed to explain
why this patient required additional resources.
Currently there is only one ICD-9-CM code available
for reporting non-traumatic intracerebral hemorrhages: 431.
This code includes intracerebral hemorrhages by general
location (e.g., cerebellar, cerebral, cortical, and subcortical)
but does not include or incorporate additional conditions,
such as cerebral compression or cerebral edema.
Traumatic cerebral hemorrhage, ICD-9-CM code set
853.xx (other and unspecified intracranial hemorrhage
following injury), does include the sub-term “cerebral
compression due to injury.” Coders should also report a
code for the specific injury when possible. This represents
a query opportunity. The codes from the 853.xx category
also include fifth-digit specificity as to reporting loss of
consciousness.
Sample query form
Consider the following query example for additional
diagnoses for the scenario described above (please refer to
your facility’s specific query policies regarding compliant
query verbiage):
Dear Dr. __________:
A review of the documentation in the record shows that the
patient was admitted on 4/6/11 with a Glasgow coma score of 8
with a repeat Glasgow score of 3 on 4/7/11, an admitting diagnosis of “intracerebral hemorrhage” (H/P of 4/6/11), as well as
being described as “unresponsive” (progress note of 4/7/11). Note
the findings of the CT and MRI (4/6/11) scans, and subsequent
physician documentation of “intracerebral hemorrhage with considerable midline shift at the level of the lateral ventricles.” Note orders for
IV steroids and emergent surgical evacuation of the hemorrhage to
“reduce intracranial pressure” (progress note of 4/7/11).
If one (or more) of the following accurately describe any associated additional diagnoses for this patient, please provide this documentation in your progress notes and discharge summary:
No additional diagnoses indicated
Cerebral compression/compression of brain
Cerebral edema
Coma
Other condition (please indicate): _________________
Clinically unable to determine
A final word of caution: The proliferation of external
auditors (e.g., Recovery Audit Contractors) to identify fraudulent practices in the Medicare and Medicaid systems has
led to increased scrutiny of diagnoses that, when reported,
result in additional revenue. When querying a provider for an
additional diagnosis, such as cerebral edema or compression
of brain, make sure that your query incorporates the clinical findings from the radiology report and the treatments
rendered, and that the documentation remains consistent
throughout the record, including the discharge summary.
Editor’s Note: Spryszak is CDI education director for HCPro, Inc.,
in Danvers, MA. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education,
leadership, and program development. E-mail your questions to her at
[email protected].
In addition to open registration classes, ACDIS also offers the Clinical
Documentation Improvement Boot Camp as an on-site program. To
explore the possibility of bringing Lynne Spryszak to your facility for a
CDI Boot Camp or other training program, call 800/780-0584 or
e-mail [email protected].
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© 2011 HCPro, Inc.
October 2011
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